Family dysfunction

Double Bind (Bateson)

Expressed emotion (Vaughn and Leff 1976)

Evidence for particular differences in family relationships as a cause of schizophrenia is fairly weak. However there is support for idea that family relationships and interpersonal communication may well be associated with maintenance of condition and rate of relapse, particularly for those returning from a hospital stay. Specifically, the degree of “expressed emotion” can be a strong predictor of relapse:

What is Expressed Emotion?

  • Negative
  • Hostile
  • Critical
  • Involved
  • Concerned

Relevant research studies

Brown (1972) and Vaughn and Leff (1976)


  • relapse rates in people with schizophrenia returning home after hospitalization
  • when expressed emotion high 51% relapse, expressed emotion low 13%
  • also the more time spent in face-to-face interaction the greater chance of relapse
  • highest relapse rate (92%) was found in homes with:
    • High degree of expressed emotion
    • High degree of face-to-face interaction
    • Patient is not taking his or her medication


  • Expressed emotion is not the only a trigger for relapse, since 1 in 10 were readmitted even without this mediating factor, but the rate was much higher for “high EE” group so it may be influential
  • Caution of correlational research: maybe people with worst cases prompted greatest attention from family and this underpinned both relapse rate and communication style; correlations can be mediated by many other factors which need to be controlled and taken account of
  • Concern over how IV was operationalised; observer bias; Hawthorne effect (expectancy) maybe more of some aspects of expressed emotion shown when observed (social desirability of showing concern and involvement); maybe more criticism and hostility due to stress of study
  • Likely that not taking medication also created tension within the family expressed negatively toward the patient as patience wears thin
  • Strength: results of this study have been replicated many times across wide range of cultures
  • Positive applications as training could be provided by health professionals about best ways to interact with patient in order to minimise relapse rate; however family may need support from outside agencies as they should not feel guilty if patient does relapse as not necessarily their fault

Hogarty (1991)

Findings: EE theory has helped to inform advice for families of returning schizophrenics; is now included in many treatment programmes; the programmes have successfully reduced relapse rate


  • If family treatment plan works it shows the theory may well be valid
  • although treatment aetiology fallacy so beware!
  • May simply be the attention and support of professionals has helped family to provide more stable environment and thus it is not necessarily a change in communication style that has elicited improved relapse rate
  • Also professionals may be less likely to suggest readmittance of patient who has come from family following treatment plan; expectancy bias from professionals

Goldstein, (1998)

Findings: Theory should predict lower relapse rate in schizophrenics who do not return to any family (estranged/disowned); this is not the case.

Implications: in estranged schizophrenics many other factors influence whether they relapsed or not